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APPLICATION FOR PERMIT L- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and,the Rules and Regulations of the San Joaquin Local Health District.L-1, _ Job Address ` 62 C:(A)A!5 H2()GTOQ Si. city g D�6 4- , Lot Size PM C 1 '1 (_�-L r(1 v e Address Phone w I/Q0 Lt '[P - 0 Owner's Name A ContractorD.A P19AR25H L56^3SAddress n ,'LOiiG� icense NoPhone a-V6e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 ` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION PIC(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Y, Commercial_ Other Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X_Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal (� Distance to nearest: Well Foundation Property Line \ \ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compenss- tion laws of California." The applicant DS call for all re fired 'ts actions. mplete drawing on reverse 'si�de,],-_ ,, ..,t--�7 Signed Title: ��1 1 r t'�.+ �� Date: C FOR DEPARTMENT USE ONLY 'J '— Application Accepted by Date 3 -� '-/ Area Pit or Grout Inspection by ./ Date Final Inspection by Date Additional Comments: _ �7i7'l'7-r X �f 3 6 S O .�"1, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8237104 ❑ Tra6y 8M-63d5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CCK RECEIVED 6Y DATE PERMIT'NO. s EH 3211REV.i/951 i EH 424 ✓✓✓ �./ C